a wasted day

In case anyone needed further confirmation, you may have my professional assessment: Step 2 CS is a waste of time and money on everybody’s part (everybody, because NBME swears they’re not making a profit on it, which is a bit hard to believe).

I left Thursday evening, and had the pleasure of going through one of the busiest airports in the US. (NBME says they arranged for CS to be in these six cities because of ease of access by air. I say, that if the cities are such hubs that there are minimum two-hour delays coming in or out, that’s not a great place to try to get in and out of on a tight schedule, like for a test.) As a result, I didn’t get to bed till midnight, and didn’t sleep much, what with the planes overhead all night.

Friday morning: Lock all your pens, any penlights, any papers, any book material at all (this is what was the last straw to me: not to have access to any books of any variety for 8 hours!), wallet, purse, etc, in a big black closet. Sit through an introductory video, which included such revelations as, The examining table has a pull-out extension if you wish the patient to lie down; The examining table has a pull-out step on the bottom to assist the patient in getting up and down; The otoscope on the wall may not work if its green switch has been turned off; and so on. (I’m going to exercise self-control, and refrain from commentary until I finish the narrative.) Line up in order by numbers pinned on your jacket, and march Indian-file behind the proctors to reach the examining rooms. I felt about four years old – or would have, if my parents hadn’t spared me from experiencing preschool.

A very healthy regard for the NBME’s internet surveillance capacities restrains me from telling you what I think of some of their patient scenarios. Let’s just say I know more physical exam maneuvers than they thought to tell their patients about, so when I got to the esoteric ones, the patients gave contradictory responses, and I had to guess what they intended from the most common ailments. Also, their patients are ridiculously rote: (The following is imaginary, and bears no relationship to the actual exam that I saw, and any resemblance to real simulated patients is entirely unintentional) They sit up straight on the table, look at the wall behind you, and say, Good morning, doctor; yes, doctor, my neck does hurt; no, doctor, the pain does not radiate either to my leg or to my foot; yes, doctor, I have had some headaches; no, doctor, I have not had any nausea, vomiting, or abdominal discomfort of any kind. I told one of them she probably had cancer, and she stared straight ahead and said, All right, doctor; no, doctor, I do not have any questions. So, their answers are totally unlike real patients. Also, you ask them one semi-appropriate question, and they recite the entire history for you; which is nice of them, but unlike 85% of patients I’ve seen, who wait to have it dragged out of them, or else start giving more details than you want. Maybe that’s what patients in this part of the country are like, but I doubt it.

We spent the lunch break mostly in stiff silence, not because we felt unfriendly towards each other, but because it’s impossible to talk when the one subject foremost on everyone’s minds is totally verboten. My group eventually made up for it in passive-aggressive style by discussing our schools’ practice tests, and the kinds of patients we had seen there – as close to the forbidden fruit as possible.

I was more frustrated with the test than probably most of the other students, because I move too fast. I usually finished with the patient before the five-minute warning signal was given, and had my note written by halfway through the writing interval. Then I would close my eyes and nap (no books allowed!) for five minutes, which caused the proctors to keep coming up and asking if I was ok. And no, I didn’t get all the information I needed by that method. In real life, I would have written the note, found what I had missed, and poked my head back in to check, all before the attending arrived to listen to the report. As it was, it is against my honor to study for or put effort into stupid tests.

I am insulted and frightened that the national licensing board thinks this exam is a good idea. Do they think that I, six months from being an MD, require to be instructed in how to use an examining table and some basic instruments? Do they think that if I can diagnose cholecystitis and UTIs I’ll be a good doctor? (In other words, the range of knowledge tested here was fairly small; and those two may or may not have been on there today.) And: do they really think that 5% of US medical school graduates (the number expected to fail every year) are incompetent clinicians? If that’s the case, there’s something seriously wrong with the medical schools, and a perfunctory test administered at the end of our education is not going to fix it!

When we finished, we got a paper certificate (of our presence only) with the ECFMG insignia: the council that supervises foreign medical graduates. I got a certificate from the FMG people? What’s with that? I’m frankly xenophobic about this, or discriminatory, or whatever the word is: I highly object to the idea that a test designed to screen foreigners for their ability to work in the US medical system and communicate at least adequately with American patients is now being used as a professional requirement for me. Bother it, I speak English, and I can write you some essays in it, or recite Shakespeare in it.

I usually abhor and renounce AMSA and all its works, but on this subject I have to say, they got it right. Go read their official policy.

Bottom line: my medical school is the one responsible for teaching me how to behave with patients. They did a great job of teaching me, and of evaluating me to see that I learned what they taught. I object to someone else redundantly doing badly what my school did well – and charging me $1000 for doing it. I got nothing of value from this: No one knows for sure how this test is graded. The residency programs don’t know what to do with it; they just agreed to require one to pass it. So whether I score in the 95th percentile or the 10th matters to no one.

Met some nice people on the plane, though. I’ll have to add Catholics to my list of people I need to learn how to talk to better. I think one can be Catholic and be a Christian, but as with many mainline Protestant denominations, it’s not at all the rule.